Dr. Yekaterina Chatskaya: “Doctors Are Pushed to the Limit”

Dr. Yekaterina Chatskaya, a gynecologist at Moscow Municipal Clinic No. 180 and a leader of the Moscow local of trade union Action told Novaya Gazeta what it is like to be a trade unionist when Russia health care has entered an area of turbulence.

Yekaterina Chatskaya is a gynecologist at Moscow Municipal Clinic No. 180. In April 2015, she was involved in a work-to-rule strike by Moscow physicians, meaning that doctors spent as much time with each incoming patient as was necessary and ignored newly introduced, stringent patient-intake standards. Novaya Gazeta found out what happened with the strike and personally with Dr. Chatskaya over the past year.

How did last year’s work-to-rule strike end?

I kept a diary of my patient intakes. We analyzed the standards that took shape during the course of the strike and sent them to the head physician. It turned out our figures were similar to those issued by the Health Ministry. But the problem is that the Health Ministry’s standards are recommendations. They are not obligatory, meaning that they virtually don’t function in practice.

For example, in Moscow, a gynecologist’s standard intake time varies from twelve to fifteen minutes at different hospitals, but the federally recommended initial appointment time is twenty-two minutes. That is a fundamental difference.

In the blogs and appeals written by physicians, they say they are fighting to increase appointment times by three minutes. Do these minutes add up to something in actual practice?

Of course, they do. I have a fifteen-minute limit for seeing a single patient, and I see patients for six hours in a row without a break, meaning this limit does not include a lunch break or even a simple trip to the toilet. Over this six-hour period, according to the standards, I should be able to see twenty-four patients, who have registered in the electronic data base. But it is virtually impossible to keep up with this pace. There are complicated patients, and there are urgent cases. Old women dress slowly. They require a special approach. And you must not hurry pregnant women at all, whether someone is pregnant for the first time or has had a miscarriage in the past. But when the intake period lasts longer than six hours, it is inevitable that doctors make mistakes. Your concentration is reduced, and your eyes are tired.

You really feel by the end of the intake period that you are losing concentration and can make a mistake?

That is exactly why I started thinking about how long it takes to examine a patient in reality. Before the strike, my official intake period lasted seven hours, but in fact it came to eight hours without stopping. After the strike, we succeeded in getting six-hour schedules, while everything is still the same at other clinics.

Has what happened last year changed anything about your team?

At first, a lot of people wanted to support me, but when a group letter was drafted and we took it to other doctors for them to sign it, people got scared. The head physician called me into his office and said it was extremism, that I was going against the regime, although there were no political demands at all in the letter. Certain colleagues stopped speaking to me altogether.

But the turning point came. A year ago, we organized a local of the independent trade union Action (Deistvie). Initially, there were three of us. Now there are six times as many. We managed to stop the introduction of so-called effective contracts. One of the points in the contracts was that incentive pay would be based only on the decision of the clinic or hospital director. My pay consists of 20,000 rubles base salary and roughly the same amount in incentive pay. Under the so-called effective contracts, incentive pay would have included work assignments that are not part of my job description. Theoretically, if I had refused to mop the floors on the orders of the department head, I could have been stripped of my incentive pay. We wrote to the head physician and the prosecutor’s office. The prosecutor’s office acknowledged the decree facilitated corruption and ordered it abolished. This was a victory. But many clinics have switched to the so-called effective contracts.

Your latest protest campaign has targeted the Moscow Health Clinics Standard. What don’t you like about it?

The standard has led to a collapse at work, and not only at our clinic. During the flu epidemic, GPs were working over twelve hours a day. One doctor made a house call to a patient at one-thirty in the morning, and before that she had been seeing patients since eight in the morning, and then went out on house calls. Another colleague of mine worked three weeks without a single day off.

They have begun to drive away specialists. How? For example, a GP has to refer a patient to an endocrinologist. But to do this, he or she has to write up a full justification for the referral, get the chart and referral signed by the department head, and manage all this within the twelve-minute limit for the appointment. Management have been strongly advising GPs not to refer patients to specialists but to threat them themselves. Naturally, the endocrinologist sits there without any work. After some time has passed, management decides that since such a small number of patients come to see him, the clinic has no need of his services. Our clinic fired a mammalogist, a dentist, and an endocrinologist in this way. There is very big queue to see the gastroenterologist. But our clinic immediately set up paid appointments to see him. If you have the money, you will be served right way.

Getting an ultrasound appointment has become a disaster. In late 2014, one ultrasound specialist went on maternity leave, a second was cut, and a third resigned of her own accord. For several months, a single specialist examined pregnant women in the entire district of Mitino. It even came to blows at the terminal when two women fought over an ultrasound appointment voucher. Another big minus of the reforms has been the virtual abolition of the principle of neighborhood health care.

Now you can make an appointment with any primary care physician at a clinic. Is that a bad thing?

In our conditions, it is a bad thing, because it leads to the unavailability of medical care. For example, my primary care neighborhood covers six thousand people, although according to the standards I should be serving two thousand two hundred people. When my appointment bookings for fourteen days in advance open up at 7:30 on a Monday morning, the appointment vouchers are already gone by eight in the morning. Patients can now choose a doctor themselves, and naturally they choose doctors with good reputations. Inevitably, these doctors will be overbooked. Patients assigned to these doctors as their neighborhood doctors are simply unable to get an appointment to see them, although they will be seeing many patients from other neighborhoods.

An absurd situation has developed. The municipal health department monitors the availability of specialists. On our clinic’s overall chart, there is constantly a red light next to my name, meaning that I violate the norm, because patients sign up to see me two weeks in advance. A good doctor is not profitable to a clinic because she or he skews the statistics.

How much do you earn?

My take-home pay is between twenty-five and thirty thousand rubles a month. My last paycheck was 35,000 rubles [approx. 465 euros a month per the current exchange rate—TRR]. I have been working at this salary since April of last years. I am not paid a kopeck more, only the mandatory minimum.

Does the Moscow health department know about this situation?

Yes. We regularly appeal to them. The last appeal by primary care physicians was sent to them on March 31. After that, we got paid a little more.

Doctors are pushed to the limit. Seeing the shiny pictures on the TV, our patients imagine that everything is alright with medical care, and if something is wrong, it is the doctor’s fault. A patient can come and sit outside a doctor’s door for an hour: that means he is a bad doctor. It was that way at first, though now, it is true, patients have begun to realize that if there is a queue, it means the doctor is good. I was reprimanded when an urgent care patient got wedged into my schedule, and I was unable to see another patient before my lunch break. I asked her to wait, but when I came back fifteen minutes later, she was filling out a complaint in the department head’s office. I was reprimanded, even though the patient was seen the very same day after my break.

Would it be easier if the Health Ministry issued strict regulations rather than recommendations?

It would be ideal. We have written several times to the Moscow health department asking them to establish regulations in keeping with the Labor Code and the Russian federal government decree stipulating that a doctor should see patients for no more than thirty-three hours a week. The reply we received was meaningless, as always.

Meanwhile, our head physician issues orders that violate the recommended norms. These two realities do not intersect at all.

For example, hardship pay has been abolished throughout Moscow. Even our radiologists lost additional holidays and pay. But the federal decree clearly stipulates that medical workers who come into contact with HIV and tuberculosis should receive both additional pay and additional holidays.